**4. Conclusion**

recruitment of new vaccinators and women volunteers at the community level. This may help to reduce workload on the existing staff, and perhaps task shift to some extent. Strategies for capacity building may encompass short courses on public health epidemiology, different operational aspects in immunization for the mid-level managers, vaccinators and supervisors. All newly recruited vaccinators must undergo intensive 3 months practical training before being authorized to administer EPI injections independently. This is equally important for the Lady Health Workers who assist the EPI in national immunization days. In addition to this, refresher trainings must be arranged at least once every 2 years. The EPI management staff should undergo management trainings before assuming immunization program responsibilities at any level. This should be followed by a refresher

**4.** *Immunization policy and legislation for service delivery*: Private sector, which is the first contact of care seeking for 80% of the population in Pakistan and which is perceived as more trustworthy, must also be engaged for the delivery of routine immunization. This engagement will have the potential to improve access as well as coverage. Likewise, if task shifting to LHWs is required, legislation and policy decisions must be taken expeditiously. The program needs a clear strategy on immunization through outreach as well as fixed centers. Integration of EPI with other public health interventions such as breastfeeding, maternal nutrition, community midwifery, micronutrients etc. must be considered. A common integrated program (with common funding) will allow all health workers of various units to take up immunization related activities as their responsibility. For instance, a health staff counseling a mother for breastfeeding or nutrition must also inform her about importance and schedule of immunization. Workforce shortage in EPI will thus be addressed, and more workforce will be

**5.** *Information systems*: EPI data reliability ought to be enhanced through a critical review of the current reporting system and by objectively examining the procedures, roles and responsibilities, and also the reasons for its under-performance. Employing newer technologies (i.e. GPS, tablets, smart phones etc.) can potentially improve the timeliness and

**6.** *Engaging communities*: Campaigns for demand creation need careful planning and coordination with communication experts. Increase in the allocation of funds for mass campaigns, and to the districts to customize messages in their local context is needed. Developing a deeper understanding of locally held perceptions or misperceptions that shape the behaviors of the community will be helpful in certain geographical areas that have historically proved resistant to EPI efforts. Face to face communication and advocacy with local opinion leaders and community elders should be continued. Such engagements with communities have shown to be fruitful for increasing the coverage of

**7.** *Risk analysis*: Periodic assessment of the high risk, high priority districts and mapping of vulnerable populations must be carried out. Similarly, profiling of HR and logistic gaps is imperative. Real time information using cell phone technology can be assimilated in a dashboard where monitoring teams should instantly pick up the shortage of HR or any

propagating the EPI messages and will be available to deliver services.

training at least once every 2 years.

74 Immunization - Vaccine Adjuvant Delivery System and Strategies

accuracy of the data.

immunization.

This chapter has endeavored to unravel a multifactorial picture responsible for insufficient immunization coverage in Pakistan. Current evidence suggests that focusing on governance of the program, improving facility-based service delivery and addressing community perceptions could result in the biggest payoffs. Within a multi-cultural milieu and a complex health system, the country presents an ideal case for embarking upon more systematic health systems and implementation research to develop an empirical evidence base and to re-build the routine immunization program to serve the people who are most in need. Moreover, research conducted in the universities must be communicated in simplistic manner to the implementers and policy makers. The current situation pleads the case for generating fresh evidence in order to review policy, programmatic approach, service delivery and stakeholder engagement for improving EPI.
